Clinical Decision Support for Disseminating and Implementing Patient-Centered Outcomes Research (PCOR) Clinical Evidence

临床决策支持（CDS）系统可以通过最小化诊断错误来增强诊断过程 和延误，这是病人安全的主要组成部分。最近的联邦法规，包括保护 获得医疗保险法案（PAMA），通过要求流动提供者 通过合格的CDS机制咨询基于证据的适当使用标准， 高级成像检查（例如，CT、MRI）。最佳实施，PAMA是一个独特的机会， 影像诊断护理的质量。然而，如果执行不力，它可能会造成中断的电子健康 记录（EHR）工作流程和低价值临床警报，对诊断成像利用率影响很小或没有影响。 哈佛医学院证据图书馆（HMS-LOE）领导了一个多学科的临床医生团队， 医学信息学家代表和分级临床证据，努力创造CDS消费品 知识工件，这是在HMS Countway医学图书馆公开提供。公有领域来源 的临床证据表示为“如果-那么”形式的临床证据逻辑声明（CELS）， 使用牛津循证医学中心开发的证据强度系统进行分级。 HMS-LOE中18%的CELS也完全以标准化的语法和格式表示（例如， 医学-临床术语命名[SNOMED CT]，快速医疗保健互操作性资源[FHIR] 临床质量语言（Clinical Quality Language，CQL）CELS是专门设计的CDS消费品，将大大 促进代表和公共传播和共享文物。 在这项研究中，我们将：1）评估FHIR，CQL和SNOMED CT的技术能力，以代表三个 以患者为中心的结果研究（PCOR）指南从HMS-LOE在一个更高层次的，结构化的 a）使用乳房MRI（代替乳房X线照相术或除了乳房X线照相术之外）来诊断乳腺癌。 B）使用CT扫描检查肺栓塞，以及 (c)对有肺栓塞风险的患者进行医师教育。此外，我们还将：2）支持PCOR CELS 在我们的医疗保健系统（布里格姆妇女医院）中有结构化的代表，以及（3） 将先前开发的CDS伪影扩展到不同的医疗保健系统（Covenant Health Inc.）与 不同的EHR实施和健康信息技术（HIT）平台。透明执行 分级和表示的知识工件将促进广泛的传播和互操作性， 不同的HIT平台、最终用户和工作流程。此外，CDS伪影的确认和评价， 包括可用性和对临床实践的影响，将促进广泛采用。最终， CDS用于诊断成像是为了加强循证的、有效的护理服务。

Clinical decision support (CDS) systems can enhance the diagnostic process by minimizing diagnostic errors and delays, which are major components of patient safety. Recent federal regulations, including the Protecting Access to Medicare Act (PAMA), encourage CDS adoption and use by requiring that ambulatory providers consult with evidence-based Appropriate Use Criteria through qualified CDS mechanisms for ordering certain advanced imaging exams (e.g., CT, MRI). Optimally implemented, PAMA is a unique opportunity to improve the quality of diagnostic imaging care. However, if poorly executed, it could create interruptive electronic health record (EHR) workflows and low value clinical alerts, with little or no impact on diagnostic imaging utilization. The Harvard Medical School Library of Evidence (HMS-LOE) led a multi-disciplinary team of clinicians and medical informaticists to represent and grade clinical evidence in an effort to create CDS-consumable knowledge artifacts, which are publicly available at the HMS Countway Medical Library. Public domain sources of clinical evidence are represented as a Clinical Evidence Logic Statement (CELS) of “If-Then” form and graded using a system developed by the Oxford Centre for Evidence-Based Medicine for strength of evidence. 18% of the CELS in the HMS-LOE are also fully represented in standardized syntax and formats (e.g., Nomenclature of Medicine-Clinical Terms [SNOMED CT], Fast HealthCare Interoperability Resources [FHIR] and Clinical Quality Language [CQL]). CELS are specifically designed to be CDS-consumable and will greatly facilitate representation and public dissemination and sharing of artifacts. In this study, we will: 1) Assess the technical capability of FHIR, CQL and SNOMED CT to represent three patient-centered outcomes research (PCOR) guidelines from the HMS-LOE in a higher-level, structured representation, specifically a) Using Breast MRI (instead of or in addition to mammography) to diagnose a second breast cancer in women with previous breast cancer, b) Using CT scan for Pulmonary Embolism, and (c) Physician education for those at Risk for Pulmonary Embolism. In addition, we will: 2) Validate PCOR CELS represented in a structured representation at our healthcare system (Brigham and Women’s Hospital), and (3) Scale previously developed CDS artifacts to a different healthcare system (Covenant Health Inc.) with a different EHR implementation and health information technology (HIT) platform. Implementing transparently graded and represented knowledge artifacts will promote widespread dissemination and interoperability across varied HIT platform, end-users and workflows. In addition, validation and evaluation of the CDS artifacts, including usability and impact on clinical practice, will enhance widespread adoption. Ultimately, the goal of CDS for diagnostic imaging is to enhance evidence-based, effective care delivery.